International Initiative on Thrombosis and Cancer (ITAC-CME)

2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer

Farge D, Frere C, Connors JM, Ay C, Khorana AA, Munoz A, Brenner B, Kakkar A, Rafii H, Solymoss S, Brilhante D, Monreal M, Bounameaux H, Pabinger I, Douketis J, and the International Initiative on Thrombosis and Cancer (ITAC) advisory panel
Lancet Oncology 2019. DOI: https://doi.org/10.1016/S1470-2045(19)30336-5

Abstract

Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer. These patients are at a high risk of VTE recurrence and bleeding during anticoagulant therapy. The International Initiative on Thrombosis and Cancer is an independent academic working group aimed at establishing a global consensus for the treatment and prophylaxis of VTE in patients with cancer. The International Initiative on Thrombosis and Cancer last updated its evidence-based clinical practice guidelines in 2016 with a free, web-based mobile phone application, which was subsequently endorsed by the International Society on Thrombosis and Haemostasis. The 2019 International Initiative on Thrombosis and Cancer clinical practice guidelines, which are based on a systematic review of the literature published up to December, 2018, are presented along with a Grading of Recommendations Assessment Development and Evaluation scale methods, with the support of the French National Cancer Institute. These guidelines were reviewed by an expanded international advisory committee and endorsed by the International Society on Thrombosis and Haemostasis. Results from head-to-head clinical trials that compared direct oral anticoagulant with low-molecular-weight heparin are also summarised, along with new evidence for the treatment and prophylaxis of VTE in patients with cancer.

More about these guidelines

Despite the development of national clinical practice guidelines on VTE treatment in cancer patients, implementation of guidelines has been suboptimal worldwide and thus substantial knowledge gaps remain. ITAC-CME sought to establish a common international consensus addressing practical, clinically relevant questions in this setting. These updated recommendations also address the use of direct oral anticoagulants (DOACs) in the treatment of VTE for patients with cancer. The 2019 international guidelines provide recommendations for:

Treatment of established VTE

  • Initial treatment of established VTE
  • Early maintenance (up to 6 months) and long-term (beyond 6 months) treatment
  • Treatment of VTE recurrence in patients with cancer on anticoagulant medication
  • Treatment of established central venous catheter-related thrombosis

VTE prophylaxis

  • Prophylaxis of VTE in patients with cancer undergoing surgery
  • Prophylaxis of VTE in medically treated patients with cancer
  • Prophylaxis of central venous catheter-related thrombosis

Special clinical situations

  • VTE treatment in patients with brain tumours
  • VTE treatment in in patients with cancer and thrombocytopenia
  • VTE treatment in in patients with cancer and renal failure
  • VTE treatment in pregnant patients with cancer
  • VTE treatment in patients with cancer who are obese